What are the effects of diabetes on fertility?

Diabetes and Its Effects on Fertility

Diabetes significantly impacts fertility in both men and women, requiring preconception glycemic control with target A1C <6.5% to minimize reproductive complications and optimize fertility outcomes. 1, 2

Effects of Diabetes on Female Fertility

Pregnancy Complications and Risks

• Diabetes increases risk of:
  • Spontaneous abortion
  • Fetal anomalies (especially anencephaly, microcephaly, congenital heart disease, renal anomalies)
  • Preeclampsia
  • Fetal demise
  • Macrosomia
  • Neonatal hypoglycemia and respiratory distress syndrome 1
• Long-term risks to offspring include increased likelihood of obesity, hypertension, and type 2 diabetes later in life 1

Preconception Management for Women

• Glycemic Control: Target A1C <6.5% (48 mmol/mol) before conception to minimize congenital anomalies and pregnancy complications 1, 2
• Medication Review: Discontinue potentially teratogenic medications:
  • ACE inhibitors
  • Angiotensin receptor blockers
  • Statins 1, 2
• Screening and Assessment:
  • Thyroid function (5-10% of women with type 1 diabetes have thyroid disorders) 2
  • Renal function (serum creatinine and urinary albumin-to-creatinine ratio) 1
  • Retinopathy screening (dilated eye exam before pregnancy) 1
  • Assessment for neuropathy and cardiovascular disease 1

Multidisciplinary Care Approach

• Optimal management includes team with:
  • Endocrinologist
  • Maternal-fetal medicine specialist
  • Registered dietitian
  • Diabetes educator 1

Effects of Diabetes on Male Fertility

Semen Parameters and Sperm Quality

• Diabetes negatively affects:
  • Sperm morphology (significantly lower normal morphology) 3, 4
  • Sperm motility (significantly reduced progressive motility) 4
  • Seminal volume (trend toward lower volume) 4
  • Spermatogenesis (altered by metabolic disruptions) 5

Sexual Function

• Higher prevalence of:
  • Erectile dysfunction due to vascular and neuropathic complications
  • Ejaculatory difficulties 6
  • These sexual dysfunctions indirectly affect fertility by reducing frequency of intercourse 6

Paternity Rates and Fertility Outcomes

• Men with type 1 diabetes show:
  • Lower rates of children compared to controls
  • Decreased fertility especially with longer disease duration 4
• Couples with diabetic male partners undergoing assisted reproduction show lower pregnancy rates 3

Prevalence Data

• Prevalence of diabetes in infertile men: 0.7-1.4%
• Prevalence of infertility in diabetic men: 35-51% 3

Preconception Counseling and Management

For All Patients with Diabetes

• Preconception counseling should begin at puberty for all individuals with diabetes 1, 2
• Effective contraception should be used until glycemic targets are achieved 1
• Family planning discussions should address:
  • Risks of congenital anomalies with poor glycemic control
  • Importance of achieving near-euglycemia before conception
  • Potential pregnancy complications 2

Monitoring During Preconception Period

• Regular A1C testing to assess glycemic control
• Frequent self-monitoring of blood glucose
• Regular follow-up (every 1-2 months) to adjust treatment regimen 1

Clinical Pitfalls and Considerations

• Unplanned pregnancies: Significantly higher risk of congenital anomalies due to poor glycemic control during organogenesis (5-8 weeks gestation) 1
• Medication transitions: Plan transition from oral agents to insulin before conception when indicated 2
• Diabetic complications: Pregnancy may worsen existing retinopathy, nephropathy, or cardiovascular disease 1
• Epigenetic effects: Diabetes may cause epigenetic modifications during spermatogenesis that could potentially affect offspring health 5
• Underrecognition: Male fertility issues in diabetes are often overlooked but require attention and evaluation 6, 3

Conclusion

Both men and women with diabetes face significant fertility challenges that require comprehensive preconception care. Optimizing glycemic control before conception is essential for improving fertility outcomes and reducing pregnancy complications.